HospitalInspections.org

Based on observation, document review and interview, it was determined for 1 of 10 (Pt #1) patient, the Hospital failed to meet the emergency needs of the patient in accordance with acceptable standards of practice by failing to appropriately monitor a patient receiving pain medications with the potential for respiratory depression. Pt. #1 was found unresponsive, cardiopulmonary resuscitation initiated and the patient expired subsequently. This has the potential to affect all patients in the Emergency Department.

Findings include:

1. Pt #1's record was reviewed throughout the survey. Pt #1 was a 40-year-old patient with a significant medical history including Type 1 Diabetes Mellitus, Chronic Kidney Disease requiring dialysis and Alpha-1-antitrypsin deficiency (a genetic condition that can cause lung and liver damage), and a history of small bowel obstruction with colostomy.

The patient arrived to the Emergency Department (ED) via ambulance on 5/23/2025 at 4:33 PM. Pt #1's chart noted the following: Per the Patient Care Timeline (5/23/2025 16:33 [4:33 PM] to 5/23/2025 19:30[7:30 PM]), triage of the patient was started by the assigned nurse (E #13) at 4:34 PM and completed at 4:37 PM. A pain assessment was documented at 4:39 PM, noted to be rated at a 10 out of 10 and located in the abdomen. At 4:41 PM, the Mid-level provider (Advanced Practice Nurse),( E #12) was assigned to the patient, with the MSE (Medical Screening Examination) being completed by E #12 at this time.
The ED Triage Notes entered by E #13 at 4:41 PM stated "Pt to ED from home via GHAS c/o (with complaints of) abdominal pain and vomiting. Pain rated 10/10 and described as burning. VSS (Vital signs stable). A&O (Alert and oriented). Cooperative at this time.

The ED Provider Notes entered by E #12 at 5/23/2025 7:23 PM stated, "This 40-year-old patient ...arrives via EMS (Emergency Medical Service) for complaints of abdominal pain, nausea and vomiting that started this afternoon. Patient yelling and not being very cooperative during exam. She denies any chest pain, shortness of breath. Denies any known fevers. No other complaints at this time." The physical exam included in this provider note stated "Appearance: She is obese. She is ill-appearing. She is not diaphoretic (excessive sweating). Cardiovascular: (Heart) Rate and Rhythm: Normal rate and regular rhythm ...Mental Status: She is alert and oriented to person, place and time."

The Patient Care Timeline noted orders placed by E #12 at 4:44 PM for labs to be drawn, as well as medication orders for fentanyl 75 micrograms (opioid pain medication) and Zofran 4mg (antiemetic to prevent vomiting), to be given via intravenous route. The orders were acknowledged by E #13 at 4:45 PM. It was noted at 5:05 PM, the opioid and antiemetic medications were administered by E #13. It was noted at 5:12 PM, that the ordered labs were drawn by E #13.

The Patient Care Timeline lacked documentation of a reassessment of Pt #1's pain level following administration of the opioid and antiemetic medications. The Patient Care Timeline lacked documentation of rounding on Pt #1 (regular visiting by ED staff to assess patient condition).

A review of "Elsevier Pain Assessment and Management" guidance provided by the Hospital was completed and states: "PROCEDURE ...8. Administer analgesics as ordered. 9. Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition. Assess the patient for adverse effects of the medication (e.g., respiratory depression) ...MONITORING AND CARE ...6. Assess, treat, and reassess pain."

A review of the policy "Emergency Department Standards of Care" was completed. The policy states "PROCESS ...Ongoing Assessment ...4. Record all treatments and procedures: c. Also recorded are medication type, route of administration, time, signature of personnel and response to medications."

An interview was conducted with the ED Director (E #9) on 5/11/2025 at approximately 11:40 AM. During discussion regarding patient rounding in the ED, E #9 stated there is not a policy surrounding this, but an expectation for it to be completed at least hourly. There is no standard for documentation. Some will mark it on the board as being completed, and some will enter a note. There's an opportunity for standardization there."

The Patient Care Timeline noted an order placed by E #12 at 7:00 PM for a CT scan of the abdomen (medical imaging using x-rays and computer technology) for Pt #1. An ED Note at 7:06 PM by E #15 stated, "Radiology/CT staff came to desk asking for assistance on repositioning the (Pt #1) in bed so she can be transported to CT. (Named) RN arrived to room first, while this RN was on the way to the room to help, (named) RN yelled out for help and a doctor to come to the room. Upon entering the room, this RN noticed (Pt #1) was unresponsive, cyanotic (abnormal bluish discoloration of skin and mucous membranes due to lack of oxygen), and no pulse was found. CPR (cardiopulmonary resuscitation) was started by (named) RN, CPR was taken over by (named doctor) on transfer to (room) ED-02. Cardiac Arrest Code was called." The Patient Care Timeline noted the patient was transferred from Room 12 to Room 2 at 7:07 PM, with "Code Start" noted at 7:07 PM. Several entries were noted on the Patient Care Timeline regarding resuscitative measures and actions between 7:07 PM and 7:30 PM, including medication administrations and blood specimens for labs being drawn. "Code End" and "Patient discharged" were noted at 7:30 PM.

ED Provider Notes entered by the ED physician (E #14) at 5/23/2025 7:38 PM stated, "Code Blue Note, Initial Rhythm: Asystole (no heartbeat). Description of Code: The patient was noted with sonorous respirations (abnormal low-pitched lung sounds resembling snoring or gurgling), unresponsive upon physician bedside evaluation. No pulses palpated (examined by touch), and chest compressions were initiated by physician. The patient was then transferred to room 2 from room 12. The patient received multiple rounds of epinephrine, bicarb, calcium chloride, and 4 mg of IV (intravenous) Narcan given the patient's history of opiate abuse. Following multiple pulse checks, bedside echocardiogram continued to show cardiac (heart) stand still, with no coordinator contractility (no heart activity) ...Result of Code: Death, time of death 7:30 PM."

2. An interview was conducted on 7/9/2025 at approximately 9:00 AM, with the ED Registered Nurse (E #13) assigned to the patient on 5/23/2025. During discussion regarding care provided to the patient and the patient's ED episode, E #13 noted the patient arriving to the Hospital by ambulance, with the charge nurse assigning the patient to Room 12. E #13 stated, "I triaged her, got a set of vitals ...she was in a good amount of pain and was very vocal." E #13 further stating "I completed the triage and got pain medicine. I believe her vital signs were stable at the time, with no fever." E #13 noted "(E #12) was (Pt #1's) provider. She was there when the ambulance arrived, if I'm not mistaken." E #13 noted E #12 ordering pain medication, E #13 acknowledging the order in the EMR (electronic medical record) and administering the medication to Pt #1. E #13 additionally noted drawing the ordered lab specimens after administering medications, stating "I drew the labs. Paramedics put an IV in her, so I was able to draw from her line." E #13 could not recall returning to the patient room, but noted at approximately 6:30 PM, receiving a "secure chat" from the Registration personnel that Pt #1 was asleep, so was unable to register the patient. E #13 stated "Her B/P (blood pressure) on the monitor was stable and her pulse ox was around 97 (%), so I was just going to allow (Pt #1) to sleep. Not long after that, that's when imaging came out and asked if we could help pull her up in bed. That's when we found that (Pt #1) was unresponsive." E #13 noted the pulse oximetry as being continuous on the bedside monitor and could not recall an alarm going off for being outside of parameters. When discussing whether the patient was on telemetry monitoring, E #13 stated "I'm not 100% sure on that, if she was on tele (telemetry) or not. There were no cardiac concerns for this patient. I don't feel like it was super pertinent at that time." During discussion about the patient's blood glucose, E #13 stated "I believe she did have a Dexcom" but was unable to recall what Pt #1's blood glucose level was. During discussion about the Code Blue and administration of Narcan (used to reverse effects of opioid medications), E #13 stated "I feel like we were just trying to troubleshoot every avenue. We didn't know what the issue was." During discussion of how nursing assessments are completed for ED patients, E #13 stated she "asks questions and visualize the patient" and stated there is a specific place for documenting the assessment in Epic (electronic medical record system). E #13 noted that a full assessment is done where the system provides for more focused assessments in every area. E #13 noted she does not believe she completed a full assessment, stating "My main focus was treating her pain, so we could figure out what was wrong. I didn't believe I could do a full assessment at that time due to the amount of pain (Pt #1) was having. Then she went to sleep after giving the pain meds." During discussion about patient access to a call light, E #13 stated "The call light was available, and she had the call light, but she didn't push it that I'm aware of", further noting it rings up at the nurses' station when pushed. During discussion about staffing while Pt #1 was in the ED, E #13 noted she believed there was a PCT (Patient Care Technician) working that night. E #13 described PCT duties as they "check vitals, some can get labs, help patients ambulate, help with toileting needs." E #13 noted believing a PCT went into check on Pt #1, stating "I believe they're supposed to" document patient care provided, "but I'm not sure if they did or not."

3. An interview was conducted on 7/9/2025 at approximately 9:30 AM, with the ED APRN (E #12) assigned to the patient on 5/23/2025. During discussion regarding recollection of the Pt #1's ED episode, E #12 noted the patient arriving to the Hospital by ambulance with abdominal pain, stating "I ordered pain meds, labs, CT of the abdomen.", further stating "The CT tech went in to get her and she was unresponsive. They called a code (Code Blue) on her." E #12 described the death of Pt #1 as unexpected that night, though noting Pt #1 "was very ill. I believe she had just gotten out of the hospital the day prior." E #12 recalls completing an MSE on Pt #1 but could not recall what time it was completed. During discussion about criteria for placing a patient on telemetry, E #12 stated "Generally, we'd hook them up. If they're here with abdominal pain, chest pain or respiratory complaints, we'd generally put them on a monitor. If they're here for something like ankle pain, we probably wouldn't (place the patient on telemetry). "E #12 was unable to recall if the patient was being monitored with telemetry. During discussion regarding moving Pt #1 from Room 12 to Room 2 during the Code Blue of Pt #1, E #12 stated "Room 12 is so small. You can't fit all the people and the code cart in there."

4. An interview was conducted on 7/9/2025 at approximately 1:40 PM, with the ED Locum Physician (locum tenens - temporary position used to fill staffing gaps) (E #14), who provided care to Pt #1 during the 5/23/2025 visit. During discussion regarding Pt #1, E #14 could not recall Pt #1's name but stated "I do remember the incident." E #14 noted he was receiving sign-outs for the shift and stated, "The nurses came out and asked for assistance due to (Pt #1) being unresponsive, and the patient ultimately expired." During discussion regarding patient monitoring, E #14 stated, "There's a standing order that we put 99% of our patients on for vital signs, monitor and IV, but depends on the patient as to what the practitioner orders." E #14 clarified what "monitor" order includes, stating "where we monitor heart rate, blood pressure, pulse ox (oximetry - monitoring of blood oxygen level) continuously, depending on the acuity or what the provider deems appropriate, as well as temperature and standard vital signs." E #14 further clarified "heart rate" to mean continuous telemetry along with intermittent blood pressures. E #14 noted some of the exclusions for this monitoring to be patients presenting for a rash, medication refill, or pregnancy test, stating "if after the initial vital signs show the patient to be very stable, we will not do monitoring." E #14 continued by stating "If they're in with abdominal pain, it depends on factors like initial vital signs, age, or concerning presentation, but generally, yes, we will do monitoring."

5. An interview was conducted on 7/9/2025 at approximately 11:20 AM, with the Director of Quality and Safety (E #4). During discussion regarding an investigation of Pt #1's ED stay on 5/23/2025, E #4 noted an RCA (Root Cause Analysis) was completed, further stating, "We came in that night after it happened." E #4 noted being unable to share details of the RCA due to being contracted with a PSO (Patient Safety Organization). E #4 noted that the RCA process is not yet completed, as they are still working through their action plans. During discussion about why the incident involving Pt #1 was not included in the incident/adverse event log, E #4 stated she was unsure why that was not included, but stated "I guess somebody forgot to enter it into the system", and further stated she felt the miss was related to "coming in that night because staff contacted us due the unexpected death and needing support, mentally", rather than the investigation being prompted by an incident entry into their MIDAS system (platform for entering incidents that occur).

An interview with E #4 was conducted on 7/9/2025 at approximately 2:30 PM. During discussion about the Policy titled Telemetry, it was noted that the first step of the process states "On admission, the telemetry unit is placed on the patient." E #4 noted the policy as being "an inpatient policy because it talks about admission", but acknowledged the policy did not specify it as an inpatient policy, and the patient chart uses the terminology "Admission time" for an ED episode. During discussion surrounding action plans created as a result of the RCA completed following Pt #1's ED episode on 5/23/2025, E #4 stated the process of the action plans that were to be implemented by July 1st as being "Pulling a report by personnel, as to whether they are adhering to pain assessment/reassessment within the appropriate timeframes", further noting this data will then be reported on in the August Quality Meeting. During discussion about how the ED staff will be made aware of the data and areas for improvement, E #4 stated "The Manager will communicate to staff."

An interview was conducted on 7/10/2025 at approximately 12:15 PM, with the ED Director (E #9). During discussion regarding completion of education for the RCA Corrective Action Plan completed with staff during the June 2, 2025, ED staff meeting, E #9 stated "There were detailed conversations and expectations provided surrounding each of the points" that were presented to staff during the ED staff meeting. E #9 confirmed there was no signed acknowledgement by staff who attended the meeting. Additionally, during discussion of coaching provided to E #13 following Pt #1's ED stay on 5/23/2025, E #9 noted that written acknowledgements of coaching are usually signed by the person receiving the coaching.
On 7/10/2025 at approximately 12:25 PM, E #5 relayed a follow-up from E #9 that the ED Manager (E #10) did provide verbal coaching to E #13 but stated "nothing was put in writing" involving the coaching. Additionally, E #5 provided the current number of staff employed in the ED as 30 RNs, 13 Techs and 3 Transport Techs.

6. A review of Corrective Actions document with Pt #1 MRN (medical record number) was completed. The specified actions state, "Compliance with Pain assessment and reassessment documentation - Reported weekly at Nsg/Quality Meeting" and "Documentation of vital signs in alignment with ED Department Standards of Care" had an identified implementation date of July 1, 2025.
A review of the document titled "ED Department Meeting June 2, 2025, Meeting" and the associated "June Department Meetings Attendance" roster and printed Power Point slides titled 1. "Accountability", 2. "Charting" and 3. "Rounding" was completed. The document states (Topic bullet point #6) "Accountability discussions: Charting: -Discussion around C-SSRS, fall risk, pain assessment, reassessment standards, full focused assessment, VS frequency for nursing. -Discussion around VS frequency, rounding notes, patient updates, ambulation, I/O and bladder scans for techs." The Power Point slide "Charting" notes each of the above-mentioned discussion points. The Power Point slide "Rounding" states "Hourly-At Least!", "Notation is expected", and "Updated Vitals." The "June Department Meetings Attendance" roster notes 22 staff members present.